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r a APPLICATION FOR PERMIT 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone {209}..466-6781 // <br /> BATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein <br /> described. This-application is made in compliance with"San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joa in Local Health District. <br /> Job Address Q , r Subdivision Name <br /> Owner's Name 7 Address Phone 91or <br /> Contractor's Name ! a W License No. Phone .2-a <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT [] DESTRUCTION <br /> 4 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE g <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑OpenBottomManteca Dia. of Well Excavation <br /> Domestic/Private 0 Gravel Pack Tracy' Dia. of Well Casing <br /> f] Public [—I Other EJ Delta <br /> Type of Casing <br /> anon <br /> Irri <br /> V g.t' Approx. (] Eastern Specifications <br /> F-1CathodicProtection Depth p <br /> Geophysical Depth of Grout Seal <br /> { IJ Other Type of Grout <br /> Surface Seal.Installed by a 1 <br /> Repair Work bone ❑ Type of Pump H.P. State Work Done pN} <br /> Well Destruction Well Diameter 1 <br /> I_._1 Sealing Material {tap 50 J <br /> Depth Filler Material (Below 501) f— <br /> CJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION l {No septic tank or seepage pit permitted if public sewer is <br /> � Installation will serve: Residence _ Commercial T Other available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: 1 <br /> Water table depth <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> Distance to ne est: Welli157 Foundation Property Line <br /> LEACHING LINE No. & Length of linesA7f Total length/size <br /> FILTER BED Distance to nearest: Well Foundation /Q / Property Line v <br /> SEEPAGE PITS Depth Size Humber <br /> SUMPS IJ Distance to nearest: Well ICA::: Foundation /&I' Property Line %S--, <br /> DISPOSAL PONDS ❑ <br /> .x <br /> I,hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman�compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following; "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applican yst 5jall for all r q ed i pec tions. Complete draw-Ing on rev rse side. <br /> Signed X •/ Title: <br /> Hate: <br /> PR DEPARTMENT USE ONLY <br /> Application Accepted by $rea _ Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date 6 �Pz2 Q Manteca 823-7104 <br /> Final Inspection by Date G E] Tracy 835-6385 <br />+, Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAO 95201 <br /> I <br /> FEC BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> I' <br /> EH 13-24 - REV. 10/82P0-1—i n„ / 10182 500 <br />